Self-practice Program For Beating Minimally Invasive Coronary Anastomosis Using Homemade Low Fidelity Simulator
Muhammad Ibrahim Azmi1, Ashvin Krishna Nair1, Raja Amin Raja Mokhtar2, Shahrul Amry Hashim1.
1Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia, 2Universiti Teknologi MARA Hospital, Sungai Buloh, Malaysia.
BACKGROUND: We evaluate the effectiveness of a consistent and structured self-practice coronary anastomosis program using homemade low fidelity beating heart simulator.METHODS: The intervention involves a trainee with minimal distal coronary anastomosis experience subjected to an 8 weeks structured self-practice program. This comprises drills promoting dexterity and economy of movement in addition to performing a minimum of 28 non-beating anastomoses. These drills utilise specialised platforms. The subject was also given 4-weekly assessments using objective structured assessment of technical skills (OSATS) scoring. In the final 4 weeks, the subject was exposed to the use of low fidelity beating heart simulator and required to perform a minimum of 14 anastomoses. Drill jigs and simulator were made using materials that are relatively easy to source. The beating heart simulator was built using motorised building blocks connected wirelessly to a smartphone via dedicated application that was coded to enable selection of desired simulator's rate. For control, a junior consultant with minimal off-pump CABG (OPCAB) experience was compared to the subject at the end of the program. Both were tasked to perform 2 coronary anastomoses for OPCAB and minimally invasive CABG (MICS) set up. Blinded assessments of these anastomoses were carried out by 3 senior consultants using modified OSATS scoring. The outcomes that we observed were progression of anastomotic time and OSATS score throughout the program as well as anastomotic time and score compared to the control in both OPCAB and MICS set up.RESULTS: On completion, there were inverse correlations between anastomosis time and number of practice by 0.833 for non beating and 0.632 for beating. There was also an improvement in terms of OSATS scoring by 26.6%. Overall performance of the subject studied approaches the performance of the junior consultant in terms of time (OPCAB 489s vs 605s, MICS 712s vs 652s) and modified OSATS score (OPCAB 21 vs 20.7, MICS 19 vs 20.6) respectively.CONCLUSIONS: A structured self practice off-pump coronary anastomosis employing homemade simulator is an effective training tool for off-pump scenarios and MICS anastomosis that can be utilised in early years of training. Hence, we have formulated a randomised trial to prove this. 
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